Provider Demographics
NPI:1962920124
Name:LULLO, KATIE M (PT, DPT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:LULLO
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-9229
Practice Address - Country:US
Practice Address - Phone:614-685-9425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT019267225100000X, 2251P0200X
IL070023306261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0484370Medicaid